Ancillary Modalities For The Office: What Are The Best Investments?

In-office magnetic resonance imaging, in-office vascular testing, the stocking of wound care supplies and other modalities can add value to your podiatry practice. This author presents practical insights on what can give you the best return on investment and how to implement these ancillary modalities in the office.

Ancillary services have become increasingly important for podiatric physicians who are committed to staying in private practice.

Although some ancillary services are relatively easy to adopt, others are expensive and require substantial financial outlays. Even the more expensive, time-consuming services can be highly lucrative over time if you still have several years of practice ahead and if you have a group of doctors who work with the same blueprint of practice protocols.

Over the years, I have written on physical therapy, diagnostic ultrasound and other ancillary services available to the podiatric physician. For this article, I wanted to focus on new and growing trends in podiatric medicine that are not only great for patients but good for your business.  

In many cases, medical practices don’t even consider ancillary opportunities because of the upfront costs and time involved in training staff and maintaining compliance. This can be a critical mistake. While some of the concepts I discuss below may not be ideal for every practice, there are some that deserve strong consideration.

A Closer Look At The Benefits Of In-Office MRI

Offering in-office MRI is not only a revenue enhancer for your practice, it is a great tool to enhance the quality of care for your patients.

It has been over five years since our practice purchased our first lower extremity magnetic resonance imaging (MRI) machine (O-scan, Esaote) and we have not looked back. It has been a great asset for our practice and moreover, we are getting better images and reads than anywhere else in town.

I have found the average price of an extremity MRI unit is less than $275,000 along with limited build-out and shielding requirements. The O-scan system sits in an exam room (9’ x 10’), fits through standard doorframes and hallways, and works on 110-volt power. It requires no external radiation shielding as it has a built-in shield.

The return on investment on this ancillary service can easily pay for itself with patients referred to you. While the investment in an MRI may not be advisable for a solo practitioner, practices with three to five doctors should have sufficient means to cover the overhead and generate a profit.

If you are financing the unit, assuming a $5,000 to $7,000 monthly payment (the higher figure includes the maintenance contract), I have found there would need to be at least 1.5 to two scans per day to cover the overhead along with your MRI technician. The scanner typically comes with a one-year warranty and then one can have a multi-year extended service agreement. This service agreement is for four years and is folded into your lease monthly. It covers both preventative maintenance along with all parts and labor for service calls.  

Furthermore, considering that the Medicare allowable for a lower extremity MRI scan is less than $400 along with the fact that you will be paying out anywhere from $70 to $80 per read, the margin of profit is not overwhelming. Volume is your key indicator as is the case with most ancillary services.

Therefore, plan carefully with a good pro forma before signing the dotted line. Factoring in the cost of the build-out (if necessary) along with your monthly payment for the MRI unit itself (with your annual maintenance agreement), the overhead of a licensed X-ray or dedicated MRI technician ($18 to $20 per hour) and your radiology reads, you need to plan carefully and have your entire group on board to effectively and ethically utilize the service when available.

Considering a five-year financing plan on your MRI unit, based on my experience, with reasonable utilization, your practice should be able to generate a substantial profit in five years.

Although in-office MRI is a legal in-office ancillary service exempt by Stark Law under the safe harbor provisions, it is advisable to have a simple compliance agreement in place created by your healthcare attorney. A compliance agreement will state how your practice is operating legally under Stark Law along with state regulations.

Lastly, review your state local coverage determinations (LCDs) as well as Medicare and private insurer reimbursements within your state in order to create an accurate pro forma. As you will only be reimbursed for images within your scope of practice, it is important to make sure you know what you are getting reimbursed for by Medicare/Medicaid and commercial payers. The best payer at this moment is Medicare.

While buying a used MRI device can be cheaper, be careful. There are many dealers of used medical equipment who cannot be trusted. Buying new with a good warranty is a good idea if your pro forma indicates the device will be a successful and income-generating asset in your practice.  
 
How In-Office Vascular Testing Can Add Value

When people ask me which ancillary service is the biggest “no brainer” of them all, “in-office vascular testing” is always my reply. While there are several companies on the market that distribute in-office vascular testing devices, there is none better than the PADnet (Biomedix) device.

Our offices have utilized these vascular testing devices for almost a decade and the quality of the reports and the reliability of the machines have been impeccable. PADnet was the first noninvasive, cuff-based vascular testing device designed to be collaboratively read by a vascular specialist online in order to quickly provide a precise report and expeditiously address any immediate vascular concerns. One can immediately download reports and print them for referring doctors in order to provide a compliant, collaborative approach to vascular testing in the office setting.

With the average cost of a vascular device being less than $19,000 in my experience and the median reimbursement being slightly over $117 for the technical component alone (2016 Medicare national average), generating a good return on investment while providing outstanding care for your at-risk patients is very achievable. Performing fewer than five tests per week more than covers basic overhead.

The American College of Foot and Ankle Orthopedics and Medicine (ACFAOM) can provide your office staff certification to perform in-office vascular testing along with competency and performance monitoring to ensure that results match symptoms reported by each patient.

As with any ancillary service, it is vital to review your state LCD to ensure that you are documenting and appropriately billing for your services. While most states allow a podiatric physician to bill for multisegmental testing (93923) in addition to the ankle brachial index (ABI), some only allow single-level billing (93922). In addition, it is vital to remember that billing of any vascular testing for “screening” purposes is not allowable. Most LCDs clearly dictate that one must document the “vascular symptoms” (i.e. claudication) in order to bill for the vascular test.

This being the case, it is vital that the physician be thorough in creating clear protocols for utilization of the device. Asking the right questions and being thorough in documenting symptoms from your patients takes practice and discipline. Our office team utilizes pain surveys that help collect patient complaints before the doctor even enters the room.

If your practice provides comprehensive wound care and diabetic foot care services, in-office vascular testing is essential to create the kind of collaborative care consistent with a true center of excellence.

Providing Wound Care Supplies In The Office

While it is second nature for my practice to provide our patients with diabetes with diabetic shoes and, in some cases, a pneumatic removable cast walker, unfortunately, few podiatrists have taken the next step to provide their patients with wound care supplies.

It is often the case that many, without exploration into the reimbursement schedule for common topical wound care supplies, may scoff at the idea of going to the trouble and expense of stocking and dispensing wound care supplies for their patients. In my experience, those who have integrated this concept into their practice have concluded the additional efforts are well worth their time and, most importantly, the patients value the additional service.    

Why would you want to supply your patients with their wound care supplies? The better question is: Why not?

Dispensing wound care supplies:    
• Provides convenience for patients, especially patients with mobility or access issues  
• Avoids any confusion or substitution at the pharmacy
• Gives the patient the ability to start the treatment plan immediately
• Allows for a hands-on demonstration by you and/or your staff on how to perform dressing changes  
• Eliminates concerns about patients not picking up or filling their prescription from the pharmacy  
• Generates a profit center for your practice
• Requires little additional work over standard wound documentation requirements

Additionally, the use of pre-packaged kits simplifies inventory management and dispensing. The dispensing of these supplies can be handled by well-trained staff without consuming physician time.
While it is impossible to review all of the details of this concept, the compliance requirements are not difficult and the return on investment is as good as any ancillary service available to podiatric physicians.

Here is an example of the value of dispensing wound care dressings. Collagen powder topical wound dressings like Helix3 CP (Amerx Healthcare) (HCPCS-A6010) currently has a reimbursement of $34.48/gram, according to the 2017 DMEPOS fee schedule. The acquisition costs range anywhere from $11 to $13/gram. Considering that a patient with a full-thickness wound can receive up to 30 grams per wound per month, the median net profit for a month’s supply of wound dressings is approximately $700 per wound. Reimbursement allowables and amounts will vary from dressing to dressing and from Medicare to private payers, but typically have enough profit built in to cover the additional time and effort needed to dispense these products.    
I recommend that practitioners stock an adequate number of dressings they may need for the next two weeks to a month.

Here are the Medicare requirements in a nutshell for dispensing wound care dressings.
1. Wound description, grading, L x W x D (must document full thickness).
2. Exudate. Documentation must detail the amount of drainage (dry to heavy exudate).
3. Dressing size must be based on and appropriate to the size of the wound.
4. A1-A9 Modifiers = Denotes the number of wound(s) being treated.
5. Place of Service (POS) = Home (12).
6. A detailed written order (prescription) for the wound dressing(s) must be in your records.
7. Proof of delivery (receipt) signed by the patient.
8. Surgical dressings are not covered when dispensed to patients receiving home healthcare.
9. Dressing needs may change frequently (e.g., weekly/daily) in the early phases of wound treatment and/or with heavily draining wounds. Suppliers are expected to have a mechanism for determining the quantity of dressings that the patient is actually using and to adjust their provision of dressings accordingly.
10. One may provide no more than a one-month supply of dressings at one time unless there is documentation to support the necessity of greater quantities in the home setting in an individual case.  
11. It is often the case that changes in compliance rules are not widely circulated so it is imperative to stay up to date.
Dispensing dressings and supplies from your office to your patients is a key part of becoming a true center of excellence for your patients with diabetes. Like any type of DME, the rules are constantly changing. The rules, however, are not complicated if you stay on top of the changes and have a well trained staff to help ensure your documentation is in compliance. The use of a scribe in your practice and/or implementing effective documentation tools can save time and help reduce errors.  

How To Provide Practical Compression Therapy

The incidence of chronic venous insufficiency (CVI) is remarkably high among podiatric patients.¹ When patients need compression, knowing what to prescribe and what the patient will actually be able to use can be very difficult.

Although not new, Velcro gradient compression garments can provide the practitioner an innovative tool to help address venous disease and venous ulceration. Additionally, as of 2013, these compression devices are reimbursable under the HCPCS code A6545 (Gradient compression wrap, non-elastic, below knee 30-50 mmHg, each).

The key to keeping patients utilizing an adequate graduated compression garment is not only adherence but also the availability of suitable garments for the affected limb that older and often obese patients can don and doff. Although the range of “traditional” compression garments and applicators (don/doffing devices) has improved in recent years, there are still many who can cannot deal with the application of these devices due to weak hand strength, back problems, obesity and abnormal limb shape. Elderly or patients with palliative care also have problems with these devices.

The development of Velcro graduated compression systems like the FarrowWrap (JOBST USA) or the Circaid Wrap(mediUSA) was designed to address the needs of this group of patients by utilizing the principles of short-stretch bandaging with a low resting/high working pressure garment. These systems consist of a protective sock liner, over which one applies the wrap, along with multiple overlapping short-stretch bands interconnected by a spine. Patients secure the band by using Velcro. They can determine the degree of compression by applying the wrap at the near end stretch of the material as well as the circumference of the leg, the position and activity of the user.

Graduated compression occurs via the end stretch of the material as well as the shape of the limb. The beauty of this kind of system is that users are allowed to vary the degree of compression to the limb depending on their needs. Systems like this typically include a foot wrap, a lower leg piece and the option of a thigh wrap, which interconnects to the below-knee garment with Velcro. While there has been minimal research into the effectiveness of Velcro wrap compression systems, I have had tremendous success with patients who are poor candidates for “traditional” compression stockings.

When billing for any compression garment (traditional or Velcro wrap), the documentation of a venous stasis ulcer is mandatory. Additionally, the prescribed garment must achieve a minimum of 30 to 40 mmHg. When a clinician uses a gradient compression wrap for an open venous stasis ulcer, he or she must bill the A6545 code with the AW modifier. If there is no open ulcer, do not use the AW modifier. Medicare will deny claims for code A6545 without an AW modifier as statutorily non-covered.

One must use the right (RT) and left (LT) modifiers with this code. When billing the same code for bilateral items on the same date of service, bill both items on the same claim line using LTRT modifiers. The quantity of claims filed without RT and/or LT modifiers will be denied as incorrect coding.

While the posted fee schedule for A6545 is $92.23 for all states, coverage is limited to one compression garment per leg every six months.

While the LCD for the utilization of these devices requires the presence of a venous ulcer, I will often start with an Unna boot and local wound care to address the initial needs of the venous ulcer. Then I will transition the patient to a Velcro graduated compression garment before the ulcer is healed.

Providing compression garments in your office is something that can be rewarding for your patients and your practice. Training your staff on how to measure and provide these services is fundamental but not difficult. Measuring for any compression garment is essential to get the right size and fit. Sending your patients to a pharmacy or medical supply location to get a device without a thorough measurement and education regarding the proper donning and doffing techniques usually results in failure.

Additionally, recommending or allowing your patients to use a compression garment used previously by a family or friend isn’t recommended nor is recommending the use of an “anti-embolic” compression garment.

Final Thoughts

No matter which route you take toward growing your DME offerings within your practice, one thing remains the same: Success will depend on you. It will depend on you taking the time to watch patients walk and identifying patients who need bracing or AFOs. It will take you having the staff and efficiency to monitor, examine and expand your protocols to be able to support your investment ethically. Furthermore, it will rely on involving all of your doctors and staff.

It is most certainly the case that ancillary services in your practice can significantly enhance your bottom line but adding these types of services should first and foremost be about adding value, outcomes and convenience for your patients.

Never add services without a thorough pro forma review of your local LCDs and compliance details. Paying attention to details along with making sure that your practice can support and utilize the service consistently is essential. Many want to grow certain aspects of their practice but often are not willing to make the right investment in infrastructure, staffing and equipment to do it right.

Nothing worthwhile is ever easy and building a strong patient-centered practice is not an exception. While it may feel like you are alone in the jungle trying to figure out all of the answers, one thing I have learned is that there is always someone who has been there and done that. Seek out wisdom from others and always have a plan for success and failure.

Being an active member of the American Academy of Podiatric Practice Management (AAPPM) has helped me over the years to connect to those who have similar vision and purpose. It also has helped me to stay one step ahead of the curve with DME compliance, diagnostic tools and unique services for my patients.

Dr. Moore is the managing partner of the Cumberland Foot and Ankle Centers of Kentucky, and is a frequent lecturer, writer and consultant on all things practice management. He has been on the Board of Trustees of the American Academy of Podiatric Practice Management for over 10 years. He has disclosed that he is a speaker and consultant with Amerx Health Care and OHI.

References

1.    Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol. 2005; 15(3):175-84.
2.    Salary Expert. Available at https://www.salaryexpert.com/salarysurveydata/job=certified-pedorthist-cped/salary .
3.    Salary.com. Available at https://www1.salary.com/Prosthetist-Orthotist-Salary.html .